The Better Doctor

Atul Gawande discusses standards of medical care, and the dilemma of the average doctor.

In this week’s issue and here online (see Fact), in “The Bell Curve,” Atul Gawande writes about the startling differences in how well different hospitals treat the same diseases, and about the debate over whether the public should know. Here Gawande talks to The New Yorker’s Daniel Cappello about standards of care, and the dilemma of the average doctor.

DANIEL CAPPELLO: Bell curves, as you say, seem to show up everywhere in our lives; often, when we chart results, we see a handful that are extremely good, a handful that are extremely bad, and most clustered around what you call the “undistinguished middle.” What does this distribution mean for medicine?

ATUL GAWANDE: The idea of bell curves in medicine is the idea that there is a spread in our abilities as doctors. I came to thinking about them while trying to consider how I was doing as a surgeon. We’ve known for a long time that the more experience you have as a doctor the better you tend to be. But then someone recently pointed out to me the results from studies of cardiac surgery in New York State. If you look just at the experienced groups of cardiac surgeons and their hospitals, the results were still remarkably variable: there was a five-hundred-per-cent difference in the mortality rates for cardiac surgery among experienced hospitals. Well, as you look around at results in medicine, you will find that this is the norm.

You write that doctors find it disturbing to acknowledge the bell curve as it relates to their abilities. Do you see this as a specific characteristic of doctors—similar, for instance, to dismissing alternative medicine, or to scoffing at anything outside of traditional Western practices—or is it just human nature?

I’m more inclined to think that it’s human nature—the Lake Wobegon effect, it has been called. Remember how Garrison Keillor would begin his radio program by describing Lake Wobegon as a place “where all the women are strong, all the men are good-looking, and all the children are above average”? Lots of studies show that we each tend to think that we are better-looking than average, that we are smarter than average, and the equivalent happens in medicine, too. In medical practice, I, of course, think I’m doing my job as well as it can be done. But when you plot out the bell curve for physicians, you realize very quickly that half of us must be below average, and that a good ninety per cent of us are not really at the top, after all. That’s what is disturbing to acknowledge. It’s hard for most of us to admit to ourselves that we’re pretty middling, or even mediocre. It goes against the grain of what we’re promising to people, and it also goes against our idea of ourselves.

Based on your experience in medicine, how aware do you think doctors are in general of where they fall on the bell curve? Is that something that they’re actively thinking about?

No, I don’t think that we’re actively thinking about it. We’ve started to think about it only in recent years, as the pressure to measure has mounted. There are now Web sites with report cards on how we’re doing. There are U.S. News and World Report’s measurements of different hospitals. There are also initiatives from insurance companies to pay according to one’s performance. And so, suddenly, we have to start taking a closer look at these bell curves.

Your story in the magazine this week looks at how well different hospitals do with patients who have cystic fibrosis. What did you find?

The experience with cystic fibrosis is distinctive, because the Cystic Fibrosis Foundation has been collecting data on cystic-fibrosis treatment centers for forty years. The data has shown a bell curve—a wide difference in survival, depending on which center you get care from. And so they’ve had to grapple for much longer with the question of whether you could bring everybody up to the top end of the curve.

The Minnesota Cystic Fibrosis Center is singled out in your article as probably the country’s best for the treatment of the condition. What makes it one of the best?

I went there expecting to find that they had some breakthrough drug, or some kind of secret combination of therapies that offered the solution and that might then be picked up by other places. But that wasn’t what I found. For the most part, Minnesota was using the same guidelines and drugs and information as other places that weren’t doing nearly as well. What was very different, though, was Warren Warwick, the longtime leader of the program. He’s someone who simply pushes everybody harder to deliver consistency, and he has a kind of genius about how to get these kids—and adults—to stay well.

In your description of Dr. Warwick, you note one thing that sets him apart—that he thinks about each patient’s case individually. He questions all aspects of their lives, figuring out how their daily routines are affecting their wellness. How realistic is it to think that doctors across the board can begin to think about their patients that way, instead of just seeing symptoms and calculating prognoses based on symptoms described or seen at the time of a visit?

Watching Warwick take care of his patients was remarkable. He spent a little more time with his patients than I’m used to seeing—so I suppose he just has a little bit more time somehow—but even more significant is the way he goes about doing it. From the beginning, he asks, “What are we going to do to get you to live as long as you possibly can?” It’s an incredible way to frame an ordinary office visit with somebody. He then basically goes through it, step by step. He’ll figure it out and say, “Here’s where we’re falling down on being able to help you live as long as you possibly can.” And then he starts searching even further—”Well, how can I motivate you to get to that next step of performance,” or “If you are motivated, what is it we need to do to alter our care so that we can make it even better?” In every office appointment, he is not just looking for the right thing to do; he is looking for the better thing to do.

What about other diseases, like heart disease, cancer, diabetes, or aids? Are there hospitals in the country that stand out in the same way? Are there similar doctors who come to mind?

Well, I’m certain that there are similar doctors in almost every field of medicine, but I don’t know where they are. My department of surgery is one of fourteen departments of surgery around the country that have decided to share our data to figure out where the standouts are. We’re all centers that think we’re great. But, of course, all fourteen of us can’t be the best. And so the unusual thing is that we are sitting down and trying to figure out: When you have an appendectomy or a colon-cancer operation at one of our hospitals, who does the best? Are there lessons that might be learned from one place for the others? Just by collecting that data, though, we’re eventually going to find ourselves in a corner. If there are meaningful differences among our institutions—and there will be—we’ll have to decide whether or not to publicize them. And I do think that our innate reluctance to make these kinds of data public is troubling. If it turns out that where you get your care really matters to how long you’re going to live, well, how can we not let people know that information?

You write about doctors being reluctant to share their records with their peers, but aren’t there also precedents for sharing in medicine?

Well, surgery has long had a practice of actively discussing one’s complications with one’s immediate peers—peers at one’s own hospital. I think that has been key to how we’ve managed to make something as violent and dangerous as surgery succeed. But what we are more nervous about is going beyond our four walls and comparing how we are doing from one institution to the next. That we have not often done. It’s what we need to do to make all of medicine better, though.

Let’s look at it from a different point of view, from the patients’ and families’ perspectives. Even when patients know a certain hospital isn’t the “best” for their ailment, they often stay on because of other factors, like accessibility, or the doctors they know and trust. What weight do these factors have in making a care center the best for a patient?

Actually, there is a striking study along these lines. Researchers went to people having cardiac surgery in Pennsylvania, where there are report cards on how the different centers for cardiac surgery perform. The researchers focussed on patients at a center toward the very bottom of the list. And it turned out that the vast majority of those patients did not know that the ratings existed in the first place. Among the patients who had seen the information, however, many came away with the impression that the place was one of the best, even though the information showed that it was quite the opposite. We all, I think, have a certain degree of wishful thinking about the doctors and hospitals we decide to put our trust in. Given a choice of somewhere that’s nearby, with people you know, and that seems to have a good reputation with your neighbors, versus a place that might have a few numbers that look pretty good but is farther away and you don’t know anybody who’s been there, it’s not surprising that people might choose the place that, by the numbers, looks worse. I think that’s going to change over time. As information spreads about how big the differences are, and how much where you are matters, there’s going to be—and we’re already seeing this—a willingness to travel farther for the best possible care. I think that the harder part, though, is figuring out where to find it. In New York, for example, the information that’s available on the Web about how different hospitals do for cardiac surgery is from the years 1998 to 2000. Four years later, the same surgeons may no longer be at those hospitals, and it’s not clear how relevant those numbers are. We’ve got to do better than that.

Another point that you bring up is a recurring theme in the history of medicine: innovation as a driving force of progress. Yet you say that medicine today seems bound to “evidence-based practice,” and that doctors are supposed to follow research findings. What else can doctors do without essentially experimenting on their patients?

The striking thing to me about Dr. Warwick’s practice is that he is pushing beyond what the guidelines tell you to do. He has this great quote that guidelines should come with an expiration date, because they’re a record of the past. By that, I think, he means that the research that comes together to form today’s common wisdom is always ready to be overturned by new information. If you are going to be able to push beyond the results that were achieved in the past, that does require innovation—a certain kind of gamble. That said, physicians who are making stuff up as they go along are not necessarily making things better for patients—in fact, they are usually making things worse. Warwick is unusual in that he so consistently comes up with ideas that end up being adopted by other physicians, and end up helping patients.

Does grading doctors and hospitals do more harm or more good? Do doctors and medical centers become obsessed with the grades themselves, or do the grades really drive doctors to deliver the best health care possible?

This is an important question, and it’s one that is fiercely debated inside medicine. For example, the different rankings put out by magazines and Web sites are crude and simplistic, to say the least. They can have strange results that sometimes are clearly wrong. But, at the same time, we didn’t have anything before that helped patients sort out where they could get better care. And I think that people are more capable of sorting through that information in a meaningful way than we give them credit for. So, yes, only a minority of people will actually sit there and poke through the information that you might be able to download from a Web site about one hospital versus another, and some of the information will be shaky. But the bottom line is that there are wide differences in the results different doctors and hospitals achieve—there is a bell curve. Comparative information can help patients find better results for themselves. And it will also spur all of us in medicine to find ways to do better ourselves. ♦

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